Clinical efficacy of laparoscopic modified loop cholecystojejunostomy for the treatment of malignant obstructive jaundice

Clinical evaluation of endoscopic biliary stenting in treatment of malignant obstructive jaundice

BACKGROUND

Malignant obstructive jaundice (MOJ) is characterized by the presence of malignant tumors infiltrating or compressing the bile duct, causing poor bile drainage, generalized yellowing, pain, itching, and malaise. MOJ is burdensome for both the society and the families of affected patients and should be taken seriously.

AIM

To evaluate the clinical effect of stent placement during endoscopic retrograde cholangiopancreatography for relieving MOJ and the efficacy of percutaneous transhepatic biliary drainage in terms of liver function improvement, complication rates, and long-term patient outcomes.

METHODS

The clinical data of 59 patients with MOJ who were admitted to our hospital between March 2018 and August 2019 were retrospectively analyzed. According to the treatment method, the patients were divided into an observation group (29 patients) and a control group (30 patients). General data, liver function indices, complications, adverse effects, and 3-year survival rates after different surgical treatments were recorded for the two groups.

RESULTS

There were no significant differences in baseline information (sex, age, tumor type, or tumor diameter) between the two groups (P > 0.05). Alanine aminotransferase, aspartate aminotransferase, and total bilirubin levels were significantly better in both groups after surgery than before surgery (P < 0.05). The overall incidence of biliary bleeding, gastrointestinal bleeding, pancreatitis, and cholangitis was 6.9% in the observation group and 30% in the control group (P < 0.05). No significant differences in the rates of blood transfusion, intensive care unit admission, or death within 3 years were observed between the two groups at the 1-month follow-up (P > 0.05). The 3-year survival rates were 46.06% and 39.71% in the observation and control groups, respectively.

CONCLUSION

Endoscopic biliary stenting effectively relieves MOJ and significantly improves liver function, with minimal complications. This technique is a promising palliative approach for patients ineligible for radical surgery. However, further research is needed to optimize current treatment strategies and to explore their potential in treating nonmalignant cases of obstructive jaundice.

Advances in minimally invasive treatment of malignant obstructive jaundice

Malignant obstructive jaundice (MOJ) encompasses a range of diseases stemming from malignant tumors such as cholangiocarcinoma, pancreatic cancer, and primary liver cancer, among others, which cause obstruction in both intra- and extra-hepatic bile ducts. This obstruction may lead to elevated bilirubin levels, hepatic function impairment, and a low rate of successful surgical resection in clinical settings. There are various minimally invasive treatment options for MOJ, including endoscopic biliary drainage, ultrasound-guided procedures, and percutaneous biliary tract puncture drainage.

Endoscopic ultrasound-guided biliary drainage vs percutaneous transhepatic bile duct drainage in the management of malignant obstructive jaundice

BACKGROUND

Malignant obstructive jaundice (MOJ) is a condition characterized by varying degrees of bile duct stenosis and obstruction, accompanied by the progressive development of malignant tumors, leading to high morbidity and mortality rates. Currently, the two most commonly employed methods for its management are percutaneous transhepatic bile duct drainage (PTBD) and endoscopic ultrasound-guided biliary drainage (EUS-BD). While both methods have demonstrated favorable outcomes, additional research needs to be performed to determine their relative efficacy.

AIM

To compare the therapeutic effectiveness of EUS-BD and PTBD in treating MOJ.

METHODS

This retrospective analysis, conducted between September 2015 and April 2023 at The Third Affiliated Hospital of Soochow University (The First People's Hospital of Changzhou), involved 68 patients with MOJ. The patients were divided into two groups on the basis of surgical procedure received: EUS-BD subgroup (n = 33) and PTBD subgroup (n = 35). Variables such as general data, preoperative and postoperative indices, blood routine, liver function indices, myocardial function indices, operative success rate, clinical effectiveness, and complication rate were analyzed and compared between the subgroups.

RESULTS

In the EUS-BD subgroup, hospital stay duration, bile drainage volume, effective catheter time, and clinical effectiveness rate were superior to those in the PTBD subgroup, although the differences were not statistically significant (P > 0.05). The puncture time for the EUS-BD subgroup was shorter than that for the PTBD subgroup (P < 0.05). Postoperative blood routine, liver function index, and myocardial function index in the EUS-BD subgroup were significantly lower than those in the PTBD subgroup (P < 0.05). Additionally, the complication rate in the EUS-BD subgroup was lower than in the PTBD subgroup (P < 0.05).

CONCLUSION

EUS-BD may reduce the number of punctures, improve liver and myocardial functions, alleviate traumatic stress, and decrease complication rates in MOJ treatment.

Pathophysiological consequences and treatment strategy of obstructive jaundice

Obstructive jaundice (OJ) is a common problem in daily clinical practice. However, completely understanding the pathophysiological changes in OJ remains a challenge for planning current and future management. The effects of OJ are widespread, affecting the biliary tree, hepatic cells, liver function, and causing systemic complications. The lack of bile in the intestine, destruction of the intestinal mucosal barrier, and increased absorption of endotoxins can lead to endotoxemia, production of proinflammatory cytokines, and induce systemic inflammatory response syndrome, ultimately leading to multiple organ dysfunction syndrome. Proper management of OJ includes adequate water supply and electrolyte replacement, nutritional support, preventive antibiotics, pain relief, and itching relief. The surgical treatment of OJ depends on the cause, location, and severity of the obstruction. Biliary drainage, surgery, and endoscopic intervention are potential treatment options depending on the patient's condition. In addition to modern medical treatments, Traditional Chinese medicine may offer therapeutic benefits for OJ. A comprehensive search was conducted on PubMed for relevant articles published up to August 1970. This review discusses in detail the pathophysiological changes associated with OJ and presents effective strategies for managing the condition.

An alternative palliative surgical method for advanced malignant obstructive jaundice: Laparoscopic bridge choledochoduodenostomy

Background

This study introduces an alternative palliative surgical procedure called laparoscopic bridge choledochoduodenostomy (LBCDD) for patients with advanced malignant obstructive jaundice (AMOJ).

Methods

Patients with AMOJ who had LBCDD between January 2017 and August 2021 were identified from databases of two institutions in China.

Results

A total of 35 patients (male 12; female 23) with an average age of 64 years were enrolled. The average diameter of the tumor is 4.24 cm. All patients undertook LBCDD within an average operation time of 75 min with a mean blood loss of 32 ml. One patient had controlled bile leakage after the operation and two developed surgical site infection involving the epigastric orifices. All of them were solved by conservative treatment. All patients were discharged smoothly after an average hospital stay of 5.5 days, and no conversion to open surgery was required.

Conclusions

LBCDD is a safe and efficient palliative surgery, which has a good therapeutic effect on patients with AMOJ.

Pharmacokinetic Study of Nalbuphine in Surgical Patients Undergoing General Anesthesia with Varying Degrees of Liver Dysfunction

Purpose

This study aimed to characterize the pharmacokinetics of nalbuphine in patients undergoing general anesthesia with varying degrees of liver dysfunction.

Patients and Methods

Twenty-four patients were enrolled and divided into three cohorts based on liver function: normal liver function (n = 13), mild liver dysfunction (n = 5), and moderate/severe liver dysfunction (n = 6). During the induction of anesthesia, they received 15 mg of nalbuphine intravenously. Venous blood samples were collected from each patient. The plasma concentration of nalbuphine was determined using ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). The pharmacokinetic parameters of nalbuphine were calculated by non-compartmental analysis (NCA) using Phoenix WinNonlin software.

Results

Compared with the normal liver function group, the plasma elimination half-life (T_1/2) of nalbuphine was increased by approximately 33% in the moderate/severe liver dysfunction group (2.66 h vs 3.54 h, P<0.05), and the volume of distribution (V_d) increased by approximately 85% (100.08 L vs 184.95 L, P<0.05). Multivariate analysis revealed that weight and platelet were associated with clearance (CL); total bilirubin as an independent factor was associated with T_1/2, and weight associated with area under the curve (AUC_(0→∞)) independently.

Conclusion

The T_1/2, mean residence time, and V_d of nalbuphine in patients with moderate/severe liver dysfunction were prolonged or increased significantly compared with those in the normal liver function group. These data suggest that it may need to be used with caution when nalbuphine is administered to patients with moderate or severe liver dysfunction.